The DD 2870 form is an essential document used by members of the United States Armed Forces and their families to authorize access to personal health information. This form ensures that individuals can grant permission to healthcare providers and other entities to disclose vital medical information when necessary. Completing this form accurately can streamline the process of accessing health services, making it a critical step for those in need.
Ready to take the next step? Fill out the form by clicking the button below.
The DD 2870 form plays a crucial role in the military community, serving as a vital tool for members and their families. It is primarily used to request information about medical treatment and to access services under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). By filling out this form, individuals can ensure that they receive the benefits and care they are entitled to, especially when it comes to coordinating health services. This two-page document not only captures essential personal details such as the claimant’s name and address, but it also provides a space for necessary medical information. Additionally, the DD 2870 facilitates communication between military personnel and health care providers, which is critical for effective service delivery. Overall, understanding the significance of this form can empower members of the military and their dependents to make informed decisions about their health care needs.
Prescribed by: DoDM 6025.18
CONTROLLED when filled
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and howit will be used. Please read it carefully.
AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R.
PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information.
ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons.
DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information.
This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes.
SECTION I - PATIENT DATA
1. NAME (Last, First, Middle Initial)
2. DATE OF BIRTH (YYYYMMDD)
3. SOCIAL SECURITY NUMBER
4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD)
5. TYPE OF TREATMENT (X one)
OUTPATIENT
INPATIENT
BOTH
SECTION II -
DISCLOSURE
6. I AUTHORIZE
TO RELEASE MY PATIENT INFORMATION TO:
(Name of Facility/TRICARE Health Plan)
a. NAME OF PERSON OR ORGANIZATION TO RECEIVE MY
b. ADDRESS (Street, City, State and ZIP Code)
MEDICAL INFORMATION
c. TELEPHONE (Include Area Code)
d. FAX (Include Area Code)
7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable)
PERSONAL USE
INSURANCE
CONTINUED MEDICAL CARE
RETIREMENT/SEPARATION
SCHOOL
LEGAL
OTHER (Specify)
8. INFORMATION TO BE RELEASED
9. AUTHORIZATION START DATE (YYYYMMDD)
10. AUTHORIZATION EXPIRATION
DATE (YYYYMMDD)
SECTION III - RELEASE AUTHORIZATION
ACTION COMPLETED
I understand that:
a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the
TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the basis of this authorization.
b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re- disclosed and would no longer be protected.
c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR 164.524.ss
d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to
obtain this authorization.
I request and authorize the named provider/treatment facility/TRICARE Health Plan to release the information described above to the named individual/organization indicated.
11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE
12. RELATIONSHIP TO PATIENT
13. DATE (YYYYMMDD)
(If applicable)
SECTION IV - FOR STAFF USE ONLY (To be
completed only upon receipt of written revocation)
14. X IF APPLICABLE:
AUTHORIZATION REVOKED
15. REVOCATION COMPLETED BY
16.DATE (YYYYMMDD)
17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE
SPONSOR NAME:
SPONSOR RANK:
FMP/SPONSOR SSN:
BRANCH OF SERVICE:
PHONE NUMBER:
DD FORM 2870, DEC 2003
Reset
After gathering all necessary documents, you can proceed to fill out the DD 2870 form. This form requires accurate information to ensure proper processing of your request. Follow the steps below carefully to complete the form correctly.
What is the DD 2870 form?
The DD 2870 form, officially titled the "Authorization for Homeless Veterans’ Reintegration Programs," is utilized by individuals seeking assistance from veteran reintegration programs. This form formally requests that the Department of Veterans Affairs or other participating organizations provide services to eligible homeless veterans.
Who needs to fill out the DD 2870 form?
Homeless veterans seeking support in reintegrating into society should complete this form. It is required for individuals who wish to access services, resources, and programs aimed at aiding their transition back into stable living situations.
Where can I obtain the DD 2870 form?
The DD 2870 form can typically be obtained from various sources, including veteran service organizations, local VA offices, or online through the official Department of Defense or Department of Veterans Affairs websites. Many community organizations that serve veterans may also have copies available.
What information is required on the DD 2870 form?
Individuals filling out the DD 2870 form will need to provide personal information, including their name, contact details, military service history, and specific services they are seeking. This information helps organizations determine eligibility and the appropriate level of assistance needed.
How is the DD 2870 form used?
The completed DD 2870 form is submitted to the appropriate agency to initiate the process of accessing services for homeless veterans. It serves as a request for programs that may include job training, housing assistance, and other support services aimed at helping homeless veterans achieve stability.
What happens after I submit the DD 2870 form?
After submission, the form will be reviewed by the specific organization to which it was sent. Representatives will assess eligibility and reach out to the applicant to discuss available services. This step may involve an interview or further documentation to establish needs and priorities.
Is there a deadline for submitting the DD 2870 form?
There is no specific deadline for submitting the DD 2870 form, as it can be completed and turned in at any time when seeking assistance. However, applicants are encouraged to submit the form as soon as possible to facilitate timely access to available services.
Can someone help me fill out the DD 2870 form?
Yes, individuals may receive assistance from veterans service officers, social workers, or staff at organizations that specialize in helping homeless veterans. These professionals can provide guidance on how to complete the form accurately and effectively.
What if my circumstances change after submitting the DD 2870 form?
If a veteran’s circumstances change after submission, it is important to inform the agency that received the form. Changes could include updates to contact information, changes in housing status, or new support needs. Keeping the agency informed ensures that services remain relevant and effective.
Filling out the DD 2870 form can be a straightforward process, but several common mistakes can lead to delays or complications. One frequent error is omitting required information. Individuals often forget to fill in necessary fields, such as personal identification details or contact information. Incomplete forms can result in processing delays, as the reviewing authorities may need to reach out for missing information.
Another common mistake is providing inaccurate information. Sometimes, people misread the questions or mistakenly input wrong data, like incorrect Social Security numbers or addresses. This inaccuracy can complicate the verification process and may result in additional steps to correct the information. Double-checking all entries before submission is crucial.
Many individuals fail to provide the correct documentation required to support the information on the form. The DD 2870 may require specific proofs of identity or eligibility, depending on the involved circumstances. Not attaching necessary documents can delay approval and create confusion during the assessment.
A prevalent issue stems from not properly signing or dating the form. A signature is a key part of the submission, and skipping this step or signing incorrectly can result in rejection. Always ensure that a signature is placed where required and that the date aligns with submission.
Additionally, it is essential to use the right submission methods. Some people mistakenly send the form to the wrong address or submit it via unauthorized methods. It can lead to further delays. It is always advisable to confirm the correct submission guidelines before sending the form.
Failing to keep a copy of the submitted DD 2870 is another oversight. Without a personal record, individuals may struggle to reference their submission or clarify any issues that arise later. It is wise to maintain a copy for personal records.
Lastly, many neglect to follow up on the status of their submission. After sending the form, it’s important to check in with the relevant authority to confirm receipt and inquire about any further requirements. Proactive communication helps to ensure that the process moves forward smoothly.
The DD 2870 form is essential for service members and veterans seeking benefits related to health care and other services. When completing the DD 2870, certain additional forms and documents may be required to provide further context or information. Here are five common forms and documents that often accompany the DD 2870.
Understanding these accompanying forms can streamline the process of submitting the DD 2870. Accurate and complete documentation helps ensure that individuals receive the benefits they are entitled to without unnecessary delays.
The DD 2870 form is an essential document used primarily in military settings, specifically for requesting a copy of a service member’s medical records. Similar documents exist, serving comparable purposes. Below are six documents that resemble the DD 2870 form in functionality.
When filling out the DD 2870 form, it is essential to follow certain guidelines to ensure accurate submission and processing. Below is a list of dos and don’ts to help you complete the form effectively.
The DD 2870 form, also known as the "Authorization for Consent to Release Medical Records," is often misunderstood. Here are five common misconceptions about this form.
The DD 2870 form, also known as the "Authorization for Disclosure of Medical or Dental Information," is an essential document used by the military and veterans for accessing health care services. Here are some key takeaways to consider when filling out and utilizing this form:
Understanding how to fill out the DD 2870 form correctly not only streamlines your access to essential health services but also empowers you to manage your medical information responsibly.
Qdro Meaning - Correctly completing the QDRO ensures compliance with legal standards for retirement plans.
Light Bill Template - This form facilitates communication with utilities for troubleshooting issues.